E/M Compliance Cheryl Rasbach, Compliance Auditor
E/M Compliance Cheryl Rasbach, Compliance Auditor
Presentation Outline Health First Health Plans
Introduction/Compliance 101
- HFHP Medicare Advantage Plan: What does this mean?
- HFHP obligations to comply with Federal/State Regulations
General E/M Compliance
- “If it isn’t documented, it hasn’t been done” – CMS
- Clear and concise representation of treatment
- Meet medical necessary guidelines
- 1995/1997 Documentation Guidelines
- Medical decision making – level of complexity
- Documentation: volume versus content
- E/M Documentation checklist
- Signature requirements
- ICD-10 – effective October 2013
Regulator/Payer - Provider Oversight
- Federal oversight of Mandated Compliance Programs
- State regulations – Special Investigations Unit
- Obligated to monitor/audit providers: safeguard the Medicare program
Auditor’s Perspective
- Key Components of E/M codes: history, physical exam, medical decision making
- Examples of Medical Decision Making: minimal, low, moderate, high
- Table of Risk
- Face-to-face time requirements
- Consultations – documentation requirements
- Incident-To requirements
- Electronic Medical Records – pro’s and con’s
- Documentation is the “Key to Success”
Preparing for an E/M audit
- Provider Self Audits
- Importance of participation
- Responding to overpayments: your rights as a provider
- Examples of provider’s non-compliance
- Coming Soon - Provider Mandated Compliance Programs
- Resources:
o CMS manuals/publications
o FCSO website/listservs
o OIG Annual Work Plan
o Semi-Annual Report to Congress
o Contracted Health Plans Carriers
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